REKAM I.

IDENTITAS NO RM
ASUHAN KEPERAWATAN PASIEN
INSTALASI GAWAT DARURAT
Pendidikan : ....................................
PENGKAJIAN
Triage Nama : ....................................... Alamat : .....................................
 Hitam Umur : ........... Thn/Bln/Hr *) .....................................
 Biru J.Kelamin: Laki-Laki / Perempuan *)
St. Perkawinan: Kawin/Belum*)
 Merah Tanggal MRS: ........./ ........./ 20....
 Kuning Suku/Bangsa: ................................. Jam : ...............
 Hijau
Agama : ................................. Tanggal Pengkajian: ....../ ........./ 20....
Nama Pengantar: ............................. Pekerjaan : ................................. Jam : ...............
Hub. Dgn Pasien: ............................
Kiriman Dari : .............................
PEMERIKS RESUSITASI EMERGENT TANDA VITAL URGENT NON URGENT FALSE
AAN EMERGENCY

JALAN Sumbatan Bebas Tekanan Darah Bebas Bebas Bebas

….. mmHg
NAFAS

Henti nafas Frek nafas > 32 Frek Nadi …. Frek nafas >
x/menit x/menit
PERNA 24-32 x/menit

FASAN Efek nafas > 10 Frek nafas Frek nafas 18-

x/menit 20 x/menit
Mengi 20-24 x/menit
Mengi

Sianosis

Henti jantung Nadi teraba Frek Nafas ….. Frek nadi 120- Frek nadi 100- Frek nadi 80-
lemah x/menit 150 x/menit 120 x/menit 100 x/menit

SIRKU Nadi tidak

teraba TD sistol < 160 TD sistol > 120 TD sistol 120
LASI mmHg – 140 mmHg mmHg
Frek nadi > 150
x/menit

TD diastole > TD diastole > TD diastole 80

Pusat 100 mmHg 80-100 mmHg mmHg
Pucat

Akral dingin
Akral dingin

CRT < 2 detik

KESA GCS < 9 GCS 9-12 Suhu ….. ˚C GCS 12 GCS 15 GCS 15

DARAN

Riwayat alergi

Makanan

Obat
 Lain-lain

TB: ...................... CM, BB: ...................Kg Alat Bantu yang dipakai: ................................................................................
DIAGNOSA MEDIS:

II. RIWAYAT KEPERAWATAN Keluhan utama Saat ini:............................................

Alasan Masuk RS: ...............................................
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Upaya yg telah dilakukan: .................................................................................................................................................

Riwayat Penyakit Yg pernah diderita:

Pernah menderita penyakit: .......................................................................Kapan: ................................................................

Pernah dioperasi: .......................................................................................Kapan: .................................................................

Pernah dirawat di RS Karena: ....................................................................Kapan: ...........................Lamanya: .....................

Alergi Obat: .................................................................... Alergi Makanan: .......................................................................

III. OBSERVASI DAN

PEMERIKSAAN FISIK 3. Tanda Vital:

Tensi : ............./ .............mmHg Suhu : ...............O C

1. Keadaan Umum: ........................................................
2. Kesadaran: Compos Mentis Apatis Dilirum Nadi : .....................X/Menit Pernapasan : ...............X/Menit
Somnolent Sopor Coma
4. Pernapasan (Airway & Breathing= B1) 5. Cardiovasculer (Blood=B2)
Sesak Napas: Ya Tidak Orthopnoe Denyut Nadi: Ada Tidak ada
Pernapasan : Ada Tidak ada ................................................................................................
Cyanosis: Bibir Kuku/Jari-jari Tidak Nyeri dada: Tidak Ya, Bila “Ya” Jelaskan:..................
Bentuk Dada: Simetris Tidak Simetris
Gerakan Pernapasan: Cuping Hidung See Saw ..............................................................................................
Retraksi Intercostal Retraksi Irama Nadi: Tertur Tidak teratur
Subkavikula Palpitasi : Tidak Ya
Pola Napas: Cepat dangkal / Dalam*) Perfusi : Hangat Kering Merah Pucat
Batuk : Berdahak Kering Darah Tidak Akral Dingin Basah
Suara Napas: Vesikuler Ronchi Kiri/Kanan*) CRT : <3 detik >3 detik
Rales Frition Rub JVP : <5 cm >5 cm
Wheezing Kiri/Kanan*) Bunyi Jantung: S1/S2 Murni /Abnormal S3 S4
Lainnya:............................... Murmur Gallop Thrill
Alat Bantu Napas: Canul Nasal Masker Biasa Edema: Anasarka Palpebra Extremitas atas
Masker rebrhiting/Non Rebrhiting*) Extremitas bawah
OT NT Tracheostomi Ventilator Aktivitas Derajat : I II III IV
Lainnya: ............................
Keluhan Lainnya: ................................................................
Keluhan Lainnya: ...............................................................
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Masalah Keperawatan: .......................................................... Masalah Keperawatan: ..........................................................

 Nama Pasien: ........................................... No RM :
6. Persarafan (Brain=B3) 7. Perkemihan / Eliminasi Uri (Bledder=B4)
Kecurigaan fraktur servical: Tidak Ya Prod urine: ............ml; ..........x/hari; Oliguri/Anuri/Poliuri*)
Retensiourine Inkontinensia Urine
Jelaskan:............................................................................
GCS: E: ............ V: .............. M: .............. Total: ...........
Refleks Pupil: ( ) Isokhor Anisokhor Disuria: Tidak Ya, Bila “Ya” Jelaskan:.......................
Ukuran: ..............│............mm
Refleks Patologis: Rangsang Meningeal: Kaku Kuduk ..............................................................................................
Kernig sign Budsinzki Neck Sign
Brudsinzki’s Contralaterl Leg sign Babinsky(.....I.....) Warna Urine: ...............................................; Hematuri
Kejang: Klonik Tonik Fokal Umum
Palpasi: Ginjal: Teraba / Tidak Teraba*)
Grand Mall Petit Mall Tremor Twitching
Proses Pikir: Cemas Takut Gelisah Vesika Urinaria: Kosong Lunak Keras
Persepsi Sensori: Genitalia: Sirkum / Tdk Sirkum Priapismus
Penglihatan:................................................................
Hipospadia Epispadia Fimosis Kriptokismus
Penciuman:.................................................................
Blanitis Hernia Verikokel
Pendengaran:.............................................................
Pengecapan:..............................................................
Perabaan:...................................................................
Keluhan Lainnya: ...............................................................
Sakit Kepala : Tidak Ya, Bila “Ya” Jelaskan:..............

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Keluhan Lainnya: ...............................................................

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Masalah Keperawatan: ..........................................................
Masalah Keperawatan: ..........................................................
8. Pencernaan /Eliminasi Alvi (Bowel=B5) 9. Muskuloskeletal/Integumen (Bone=B6)
Keluhan: Mual Kurang/Tidak ada nafsu makan
Keluhan Nyeri: Tidak Ya, Bila “Ya” Jelaskan:..........
Muntah: .........Kali (................................................)

Nyeri Abdomen: Tidak Ya, Bila “Ya” Jelaskan:.......... .............................................................................................

............................................................................................. Fraktur : Tidak Ya, Bila “Ya” Jelaskan:.......................

.
Bekas Luka Operasi: Tidak Ya; ............................... ..............................................................................................

Bising Usus: ...........X/menit; Peristaltik: ............................... Pergerakan Sendi: Bebas Terbatas;.............................

Perkusi: Tympani Hypertimpani Pekak Deformitas: : Tidak Ya Atropi Kontraktur
Palpasi: Hepar (Tidak Teraba/Teraba) Ukuran .................... Kekuatan Otot: 1 2 3 4 5
Limpa(Tidak Teraba/Teraba) Ukuran ....................
Massa (Tidak Teraba/Teraba) Ukuran ................... Luka: : Tidak Ya, Bila “Ya” Jelaskan:.......................

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BAB: .................X/Hari; Konsistensi: ...............................
Diare Konstipasi Faeces Berdarah Melena Kedaan Kulit: .......................................................................

Rectum:............................................................................... ..............................................................................................
Turgor : Baik Cukup Menurun/Jelek
Keluhan Lainnya: ...............................................................
Keluhan Lainnya: ...............................................................
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Masalah Keperawatan: .......................................................... Masalah Keperawatan: ..........................................................

IV. PEMERIKSAAN DIAGNOSTIK V. TERAPI
 Nama Pasien: ........................................... No RM :
CATATAN KEPERAWATAN GAWAT DARURAT
JAM T.Tangan